Should Timing of First Colonoscopy Change for Women?

The current recommendation for a first colonoscopy is at age 50 for both men
and women. Yet, evidence suggests that this recommendation be revised to
reflect differences in the development of colon tumors based on sex. It appears
that tumors appear at younger ages in men, according to an Austrian study
looking at Sex-Specific Prevalence of Colorectal Cancer in Individuals Undergoing
Screening Colonoscopy. M Ferlitsch et al. JAMA. 2011;306(12):1352-1358.

Among men ages 50 to 54, the prevalence of adenomas was 18.5% compared
with 10.7% for women at the same age. More telling is the prevalence of these
adenomas in men in their early 50s which were similar to the 17.9% (95% CI
16.7 to 19.1) seen in women ages 65 to 69,

The findings suggest that "male sex constitutes an independent risk factor for
colorectal carcinoma and indicating new sex-specific age recommendations for
screening colonoscopy," according to the study authors. However, not all experts
agree.

"Other factors, particularly African-American ethnicity, but also obesity, heavy

smoking, and diabetes are associated with an increased risk of colorectal cancer
and adenomas of about the same magnitude as gender," comments Dennis J.
Ahnen, MD, University College, Denver. "Similarly, there are protective factors
such as physical activity and aspirin usage that decrease risk of adenomas and
cancer to about the same extent as female gender. It is scientifically inconsistent
to make recommendations to change screening ages on the basis of only one of
the relevant risk factors.”

Since the ideal age for screening has not been fully explored, these researchers
examined data from a national colonoscopy screening program in which the
median ages for women and men were 60.7 and 60.6, respectively.

The overall prevalence of adenomas among women was 14.8% compared to

24.9% among men, the researchers found. The prevalence of advanced
adenomas reached 8% in men, but only 4.7% in women. Advanced adenomas
were present in 5% of men ages 50 to 54 but only 2.9% in women of the same
age.

Only when women were ten years older did their prevalence of advanced
adenomas equal that of men in their early 50s. For colorectal cancer, men had a
twofold increase in risk with there a ten-year differential in prevalence.

In men ages 55 to 59, the prevalence of colorectal cancer detected on screening

colonoscopy was 1.3% while for women 65 to 69 the prevalence was 1.2%.

The authors acknowledge that potential confounding factors such as obesity and
family history were not accounted for. Despite these findings, changing the ages
for colonoscopy screening -- particularly for women -- could create problems,
according to Sidney J. Winawer, MD, of Memorial Sloan-Kettering Cancer Center
in New York City. The old message was that colon cancer was a man's disease. “

We have to be careful not to regress in our message to women. The way to

reduce colonoscopy burden and patient procedure risk is to encourage
adherence to the 10-year interval if the colonoscopy is normal, and to encourage
adherence to the surveillance intervals if polyps are removed," stated Dr.
Winawer.
The study was supported by the Fund for Preventive Check-ups and Health Promotion.

Differences Extend to Race as well as Sex

Can women forestall Offering colorectal cancer screening (CRCS) to minority

women at the time of mammography and without a physician's referral may
effectively expand screening to a vulnerable population, according Memorial
Sloan-Kettering study reported online October 25 in Cancer.

"...CRCS in the United States is inadequate in minority communities and

particularly among those who lack insurance," write Moshe Shike, MD, from the
Department of Medicine, Memorial Sloan-Kettering Cancer Center in New York,
NY, and colleagues. "Finding ways to increase screenings in these minorities
presents a healthcare challenge. The authors sought to determine whether
offering CRCS at the time of mammography is an effective way to increase
CRCS among minority women."

The Breast Examination Center of Harlem (BECH), an active, ongoing,

mammography-screening program, is a community outreach program of
Memorial Sloan-Kettering serving the primarily black and Hispanic Harlem
Community. Women at least 50 years old without a history of CRC or screening
within the last 10 years who attended BECH had screening explained to them.
Medical fitness was evaluated, and women who consented underwent screening
colonoscopy. The investigators assessed barriers to screening and strategies to
overcome them.

Of 2616 women eligible for CRCS, 2005 (77%) declined to participate, and 611
(23%) were enrolled. Even among those who refused participation, there was a
high interest in CRCS. Lack of medical insurance was the leading barrier to
CRCS, but alternative funding partially overcame this obstacle. Of the 611
women enrolled in the study, 337 (55%) underwent screening colonoscopy, and
49 (15%) had adenomatous polyps.

"Offering CRCS to minority women at the time of mammography and without a

physician's referral is an effective way to expand screening," the study authors
write. "Screening colonoscopy findings are similar to those in the general
population. Alternatives to traditional medical insurance are needed for the
uninsured."
Limitations of this study include relatively small sample size and high refusal rate.

"Considering that the cost effectiveness of breast and colon cancer screening is
comparable, formulating a funding strategy for CRCS for the uninsured similar to
that used for breast cancer screening could improve CRCS in minority
populations," the study authors write. "...Attempts to enhance colorectal cancer
screening in this population by media campaigns, provision of fecal occult-blood
test (FOBT) cards and other methods have usually not met with much success. It
appears that a comprehensive program is needed in medically underserved
areas."

The National Cancer Institute and the American Cancer Society supported this
study. The study authors have disclosed no relevant financial relationships.

Cancer. Published online October 25, 2010.